Middle Hepatic Artery Research Articles

Surgical anatomy of the cystic artery: A systematic review with meta-analysis

BackgroundThe current evidence-based systematic review with meta-analysis presents a detailed overview of the cystic artery (CA) surgical anatomy, including its origin, number, topography, and morphometry. Moreover, the surgical implications of these variants are further discussed. MethodsAccording to the Evidence-Based Anatomy Workgroup and PRISMA 2020 guidelines, the systematic review was performed using four online databases. The Anatomical Quality Assurance Tool was used to evaluate the risk of bias. Meta-analysis was performed with the R programming software. The pooled prevalence and pooled mean of different CA parameters were calculated. ResultsThe CA most commonly originated from the right hepatic artery (a pooled prevalence of 85.75 %). Other described origins (in order of frequency) were the aberrant right hepatic artery, the common hepatic, the left hepatic, the gastroduodenal, the superior mesenteric, and the middle hepatic arteries. The CA was single in 88.59 %, while it can be identified as double, triple, or absent. Most commonly, it was located inside the cystohepatic triangle in 83.83 %. Most commonly, it was superomedially to the cystic duct (77.80 %) and posteriorly to the common hepatic duct (35.08 %). The CA pooled mean length was 21.34 mm, and its diameter was more commonly over 1 mm. ConclusionThe CA surgical anatomy is paramount when operating on the gallbladder. The CA's altered anatomy and adjacent area could lead to confusion, iatrogenic injury, and prolonged surgical time. The CA depicts high morphological variability; therefore, surgeons should consider the typical anatomy and possible (usual and unusual) variants.

Prevalence and Anatomical Variations of Middle Hepatic Artery: A Cadaveric and Radiological Study

Introduction
 Middle Hepatic Artery is a hilar artery that supplies segment IV of the left hemi-liver. Anatomical Variations of this hilar artery has led to its classification into various sub-types based on its origin. Many studies have elucidated the surgical importance of MHA and in-depth knowledge of its variations is essential to minimize the morbidity during liver surgeries. In LDLT and during hepatic resections any injury to MHA and vascular compromise to Segment IV can bring in catastrophic consequences such as reduction in functional volume of left lobe in right allograft, possible graft loss in left allograft and ischemic cholangiopathy at all cases.
 Methods
 This is a cross-sectional study on 25 cadaveric Livers and 25 CECT- Abdomen arterial phase, a total of 50 Liver specimens at our center. The origin and course of MHA was accessed and characterized after meticulous dissection of cadavers and 3D reconstruction of CECT-Abdomen arterial phase. Collected data was entered and analyzed by using IBM SPSS STATISTICS 16.
 Results
 MHA was present in 76% of cases. MHA originated from RHA in 34% of cases; from LHA in 24% of cases; from RHA in presence of replaced LHA in 6%; from LHA in presence of replaced RHA in 8% and from non-left non-right hepatic artery along the axis of CHA in 4% of cases.
 Conclusion
 MHA is a hilar artery that predominately originates from RHA. It is very important for a surgeon to meticulously study the course of MHA in patients prior to liver surgeries using 3D-reconstruction of radiological images to minimize morbidities.

Novel embryological classifications of hepatic arteries based on the relationship between aberrant right hepatic arteries and the middle hepatic artery: A retrospective study of contrast-enhanced computed tomography images.

Variations in hepatic arteries are frequently encountered during pancreatoduodenecomy. Identifying anomalies, especially the problematic aberrant right hepatic artery (aRHA), is crucial to preventing vascular-related complications. In cases where the middle hepatic artery (MHA) branches from aRHAs, their injury may lead to severe liver ischemia. Nevertheless, there has been little information on whether MHA branches from aRHAs. This study aimed to investigate the relationship between aRHAs and the MHA based on the embryological development of visceral arteries. This retrospective study analyzed contrast-enhanced computed tomography images of 759 patients who underwent hepatobiliary-pancreatic surgery between January 2011 and August 2022. The origin of RHAs and MHA courses were determined using three-dimensional reconstruction. All cases of aRHAs were categorized into those with or without replacement of the left hepatic artery (LHA). Among the 759 patients, 163 (21.4%) had aRHAs. Five aRHAs patterns were identified: (Type 1) RHA from the gastroduodenal artery (2.7%), (Type 2) RHA from the superior mesenteric artery (SMA) (12.7%), (Type 3) RHA from the celiac axis (2.1%), (Type 4) common hepatic artery (CHA) from the SMA (3.5%), and (Type 5) separate branching of RHA and LHA from the CHA (0.26%). The MHA did not originate from aRHAs in Types 1-3, whereas in Type 4, it branched from either the RHA or LHA. Based on the developmental process of hepatic and visceral arteries, branching of the MHA from aRHAs is considered rare. However, preoperative recognition and intraoperative anatomical assessment of aRHAs is essential to avoid injury.

Rare and Combined Hepatic Artery Variants as Seen in Cadaveric and Postmortem Investigations: Anatomical Implications in Surgical Practice

Context: Vascular variations are an unexpected finding during cadaveric dissections, postmortems, and surgical and diagnostic angiographic procedures. Usually, such abnormalities are asymptomatic, but the existence of hepatic vasculature anomalies might cause accidental injuries to the vasculature while performing surgical procedures. Aim: This study aimed to dissect human cadavers and postmortem specimens and to examine the variations of the hepatic artery system. Materials and Method: This study was conducted on 50 specimens, with 22 conducted in the dissection hall cadavers, while 28 were collected from the postmortem among the South Indian population irrespective of age and sex and investigated for variant hepatic arteries. The data were collected between January 2014 and December 2015. Results: The results of this study demonstrated that the common hepatic artery (CHA) originated directly from the aorta in 2%, and it was trifurcated into the right hepatic artery (RHA), left hepatic artery (LHA), and gastroduodenal artery (GDA) in 8%. It continued only as the LHA in 16% and only as RHA in 4%. The RHA arises from CHA in 8%, from the superior mesenteric artery (SMA) in 10%, from GDA in 4%, and from replaced CHA in 2%. The GDA accounted for 4% of the accessory RHA's origin, while the proper hepatic artery (PHA) accounted for 2%. The LHA from the CHA in 8% replaced the origin from the left gastric artery (LGA) in 4% and replaced CHA in 2%. The middle hepatic artery was noticed in 62% of the specimens. Conclusion: Surgeons and radiologists participating in angiographic procedures must have up-to-date knowledge of hepatic artery normal variant abnormalities.

Maresin1 inhibits the NF-κB/caspase-3/GSDME signaling pathway to alleviate hepatic ischemia-reperfusion injury

Objective: To investigate the role of Maresin1 (MaR1) in hepatic ischemia-reperfusion injury (HIRI). Methods: The HIRI model was established and randomly divided into a sham operation group (Sham group), an ischemia-reperfusion group (IR group), and a MaR1 ischemia-reperfusion group (MaR1+IR group). MaR1 80ng was intravenously injected into each mouse's tail veins 0.5h before anesthesia. The left and middle hepatic lobe arteries and portal veins were opened and clamped. The blood supply was restored after 1h of ischemia. After 6h of reperfusion, the mice were sacrificed to collect blood and liver tissue samples. The Sham's group abdominal wall was only opened and closed. RAW267.4 macrophages were administered with MaR1 50ng/ml 0.5h before hypoxia, followed by hypoxia for 8h and reoxygenation for 2h, and were divided into the control group, the hypoxia-reoxygenation group (HR group), the MaR1 hypoxia-reoxygenation group (MaR1 + HR group), the Z-DEVD-FMK hypoxia-reoxygenation group (HR+Z group), the MaR1 + Z-DEVD-FMK hypoxia-reoxygenation group (MaR1 + HR + Z group), and the Con group without any treatment. Cells and the supernatant above them were collected. One-way analysis of variance was used for inter-group comparisons, and the LSD-t test was used for pairwise comparisons. Results: Compared with the Sham group, the levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), interleukin (IL)-1β, and IL-18 in the IR group were significantly higher (P < 0.05), with remarkable pathological changes, while the level in the MaR1 + IR group was lower than before (P < 0.05), and the pathological changes were alleviated. Compared with the Con group, the HR group had higher levels of IL-1β and IL-18 (P < 0.05), while the MaR1 + HR group had lower levels of IL-1β and IL-18 (P < 0.05). Western blot showed that the expressions of caspase-3, GSDME, and GSDME-N were significantly higher in the HR group and IR group than in the other groups; however, the expression was lower following MaR1 pretreatment. The Z-DEVD-FMK exploration mechanism was inhibited by the expression of caspase-3 in HIRI when using MaR1. Compared with the HR group, the IL-1β and IL-18 levels and the expressions of caspase-3, GSDME, and GSDME-N in the HR + Z group were decreased (P < 0.05), while the expression of nuclear factor κB was increased, but following MaR1 pretreatment, nuclear factor κB was decreased. There was no significant difference in the results between the MaR1 + H/R group and the MaR1 + H/R + Z group (P > 0.05). Conclusion: MaR1 alleviates HIRI by inhibiting NF-κB activation and caspase-3/GSDME-mediated inflammatory responses.

Variations in the origin of the right gastric artery: a systematic review and meta-analysis.

The right gastric artery (RGA) supplies the lesser curvature of the stomach. The prevalence of variations in RGA origins can be of interests to students, surgeons, and radiologists who wish to increase their understanding of this vessel. The aim of this study was to perform a systematic review and meta-analysis on the origin of the RGA. The PRISMA 2020 checklist was followed. Electronic databases, currently registered studies, conference proceedings and the reference lists of included studies were searched. There were no constraints based on language or publication status. Database search, data extraction and risk of bias assessment were performed independently by two authors. A random-effects meta-analysis of the prevalence of different RGA origins was conducted. A total of 9084 records were screened in the initial search. Fifteen studies were included, assessing 1971 right gastric arteries. The RGA arose most frequently from the Proper Hepatic Artery (PHA), with a pooled prevalence of 53.6% (95% CI 44.5-60.8%), followed by the Left Hepatic Artery (LHA) with a pooled prevalence of 25.9% (95% CI 18.6-32.8%), and the Gastroduodenal Artery (GDA) with a pooled prevalence of 8.89% (95% CI 4.62-13.9%). Less common origins were the Common Hepatic Artery (CHA) (6.86%, 95% CI 3.15-11.5%), the Right Hepatic Artery (RHA) (3.43%, 95% CI 0.93-7.04%), and Middle Hepatic Artery (MHA) (1.31%, 95% CI 0-3.44%). This meta-analysis provides an accurate estimate of the prevalence of different RGA origins. Anatomical knowledge combined with pre-operative planning and imaging can prevent iatrogenic injury during surgery.

Prevalence of Michel’s Type 1 hepatic arterial anatomy on CT angiography in Nepalese population

Multidetector Computed Tomography (MDCT), with an accuracy of 95-100%, is the modality of choice for preoperative assessment of hepatic artery anatomy in this era of modern hepatic surgeries. Celiac trunk is the first anterior branch of the abdominal aorta and trifurcates into left gastric, splenic, and common hepatic artery which branches into gastroduodenal and proper hepatic artery which then divides into right, middle and left hepatic arteries. Superior mesenteric artery (SMA) originates from abdominal aorta one centimeter below the celiac trunk. This “classic” anatomy pattern is seen only in approximately 61.3% of patients. This study aims at establishing prevalence of hepatic artery anatomical variations on MDCT in Nepalese population since such study has not been published in context of Nepal yet. Cross-sectional descriptive study was performed on MDCT images of all patients undergoing CT abdomen and pelvis with angiography between November 2018 and October 2022 (four years) at Nepal Medical College and Teaching Hospital. The Type of variation was categorized according to Michel’s classification. The values were further grouped under male and female categories. Data obtained was compiled and analyzed using SPSS 16. Out of 504 patients, 258 were males (51.2%) and 246 were females (48.8%). Youngest was nine years and the eldest was 93 years old with mean age of 48.1 years. The commonest variation was Michel’s Type 1, seen in 371 (73.6%) followed by Type 2 in 61 patients (12.1%) and Type 3 in 46 (9.1%). Type 4 was seen in 11 patients (2.2%) and Type 5 variant in nine patients (1.8%). Only one patient each had Type 6 and 7 (0.2 % each). Two had Type 9 (0.4%). We did not find Type 8 and 10. Statistically significant difference between male and female was found only in Type 2 with females having higher prevalence. Two patients showed celiac trunk and SMA arising from single celiomesenteric trunk of abdominal aorta, accounting for 0.4% of total cases which was tabled under unclassified category. MDCT is excellent modality to depict normal and variant hepatic arterial anatomy. Michel’s Type 1 is the commonest hepatic arterial anatomy variant and should be considered as normal “classic” pattern.

A rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy

BackgroundHepatic arterial variations were fully elaborated in anatomical monographs. Here, we aimed to present a rare case with multiple arterial variations of the liver complicated laparoscopic pancreaticoduodenectomy.Case presentationWe report a 67-year-old woman with a periampullary tumor underwent laparoscopic pancreaticoduodenectomy. Intraoperatively, the aberrant right hepatic artery derived from the gastroduodenal artery (GDA) was observed and had accidentally sacrificed due to untimely ligature of GDA. Three-dimensional reconstruction based on preoperative contrast-enhanced CT performed to better study the anatomy. It demonstrated a replaced right hepatic artery branched from the GDA and supplied right liver lobe. Meanwhile, the middle hepatic artery derived from the common hepatic artery and supplied hepatic segment IV. Additionally, the replaced left hepatic artery emerged from the left gastric artery and fed into left liver lobe.ConclusionsThe origination and course of hepatic arterial anatomy should be thoroughly assessed in planning and performing hepatopancreatobiliary surgeries. Reconstruction images of contrast-enhanced CT are helpful to visualize the vascular variations and its spatial relation with adjacent structures.

Laparoscopic Left Hepatectomy with Resection of the Spiegel Lobe Using the Modified Caudate Lobe-First Approach.

Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019). The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV. The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications. The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.

Variations in the Origin of Middle Hepatic Artery in Living Liver Donors using CT Angiography in South Indian Population: A Retrospective Study

Variations in the Origin of Middle Hepatic Artery in Living Liver Donors using CT Angiography in South Indian Population: A Retrospective Study

Anatomic Variations of the Hepatic Artery in 5625 Patients.

To analyze the origin and anatomic course of the hepatic arteries by using digital subtraction angiography (DSA) and multidetector CT in a large study sample. This retrospective study included 5625 patients who underwent liver CT and chemoembolization between January 2005 and December 2018 (mean age, 60 years ± 11 [range, 11-99 years]; 4464 males). The CT and DSA images were reviewed to evaluate the visceral arterial anatomy for variations in the celiac axis and hepatic arteries. Aberrant right hepatic arteries (aRHAs) and aberrant left hepatic arteries (aLHAs) were defined on the basis of their origin and anatomic course. Statistical analyses were performed to evaluate the association between aRHAs and aLHAs and the association between variations in the hepatic artery and celiac axis. Right hepatic arteries were categorized as being aRHAs (if originating from the proximal to middle common hepatic artery, gastroduodenal artery, superior mesenteric artery [SMA], celiac axis, aorta, splenic artery, or left gastric artery [LGA]) or as being aLHAs (if arising from the LGA, celiac axis, aorta, or SMA). The prevalence of aRHAs (15.63%; 879 of 5625) and the prevalence aLHAs (16.32%; 918 of 5625) were similar. Patients with an aRHA were more likely to have an aLHA than those without an aRHA (29.01% vs 13.97%; P < .001), and patients with an aLHA were more likely to have an aRHA than those without an aLHA (27.78% vs 13.26%; P < .001). There was no association between the hepatic arterial variations and celiac axis variations. A hypothetical anatomic model summarizing the observed variations was created. A comprehensive list of hepatic arterial variations and a three-dimensional hypothetical model for the observed variations were described.Keywords: CT, Angiography, Liver, Anatomy, Arteries© RSNA, 2021 Supplemental material is available for this article. See also commentary by Sutphin and Kalva in this issue.

English

BACKGROUND Cystic artery originates from right hepatic artery which is a branch of hepatic artery proper of coeliac trunk from abdominal aorta. Variations in the origin and course of cystic artery were observed in this study. Contents of Calot’s triangle were also studied. Knowledge of normal anatomy, variations of the biliary apparatus and the arterial supply to the gallbladder is important for surgeon. METHODS Descriptive cross-sectional study was done from April 2008 to January 2010 in 180 adult specimens and 50 foetal specimens in the Departments of Anatomy, Forensic Medicine and Pathology in Government Medical College, Thiruvananthapuram. The abdominal wall was incised and hepatobiliary region was identified and dissected. The gallbladder and coeliac trunk were identified. Cystic artery and Calot’s triangle were studied. RESULTS More than 90 percent of the cystic artery originates from the right hepatic artery in both sexes. Cystic artery originated from left hepatic artery in 4 cases, common hepatic artery in 5 cases and from middle hepatic artery in 1 case. The cystic artery within Calot’s triangle was observed in 41 %. Right hepatic artery was content in 29.9 %. Both the arteries were content in 19 %. Cystic artery and accessory hepatic duct were content of Calot’s triangle in 2.2 %. Double cystic artery was content of the triangle in 1 cadaver. Artery or duct was seen outside the Calot’s triangle in 16 cadavers. CONCLUSIONS It is important for surgeons to know the variations of cystic artery and Calot’s triangle during surgical interventions of the hepato biliary region. “Cystic artery syndrome” is a condition where cystic artery is seen winding around cystic duct although it originates from right hepatic artery. Knowledge of these variations is important for surgeons and helps in better surgical outcome. KEYWORDS Cystic Artery, Calot’s Triangle, Right Hepatic, Gall Bladder, Coeliac Trunk

A no-ligation technique to prevent intraoperative hepatic artery dissection in living-donor liver transplantation.

Intrahepatic recipient hepatic artery dissection caused by hepatic artery thrombosis is a lethal complication of living-liver donor liver transplantation (LDLT). We herein report a new surgical technique that avoids the ligation of the recipient hepatic arteries in LDLT. Patients undergoing LDLT between 2009 and 2019 were evaluated. In the second half of this period, a technique involving no ligation of the recipient hepatic artery was initiated and its impact on the incidence of intrahepatic recipient hepatic artery dissection was determined. The middle and left hepatic arteries were ligated in 195 cases (53.4%), and the no-ligation technique was used in 170 (46.6%). The incidence of intraoperative hepatic artery dissection was significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 10, 5.1%) (p = 0.0021). After propensity score matching to evaluate the patient characteristics, the incidence of intraoperative hepatic artery dissection was also significantly lower in the no-ligation group (n = 0, 0.0%) than in the ligation group (n = 6, 4.5%) (p = 0.0295). As a result, this new surgical technique is highly recommended to avoid recipient hepatic artery ligation in LDLT.

Quadrifurcation of Coeliac Trunk- A Case Report

During routine dissection of a cadaver in the department of anatomy at Seth GS Medical College and KEMHospital, we discovered a very rare type of branching pattern of the Coeliac Trunk (CT). The CT measured3cm in length and was quadrifurcating into replaced right hepatic artery, common hepatic artery, left gastricartery and splenic artery. The replaced right hepatic artery had unusual course where it ran behind theportal vein and bile duct to reach the right lobe of liver. Common hepatic artery after giving gastroduodenaland right gastric artery continued as middle hepatic artery while left hepatic artery originated from leftgastric artery. A complete knowledge of these variations are helpful for hepatobiliary surgeons and also forradiologists.

Purely laparoscopic left donor hepatectomy with middle hepatic vein and caudate lobe

Presenter: Essa Aleassa MD | Cleveland Clinic Foundation Background: The volume of liver transplantation has been limited in North America by the low number of liver grafts available from deceased donors. Furthermore, the invasiveness of performing an open living donor hepatectomy makes it a less appealing option to the public. The introduction of minimally invasive living donor hepatectomy has helped increase the number of liver living donors. This approach is growing in North America not yet disseminated yet due to its complexity. This video aims to showcase our approach to a purely laparoscopic left donor hepatectomy that includes the caudate lobe as well as the middle hepatic vein in an effort to maximize the volume and function of the donated left liver lobe graft. Methods: A 29-year-old male underwent a purely laparoscopic left liver lobe living donor with caudate and middle hepatic artery. The patient was preoperatively assessed and noted to be a suitable donor from an anatomical and functional standpoint. The left liver lobe with preserved middle hepatic vein and caudate lobe was resected and donated to a living donor liver transplant recipient. Results: The patient tolerated the procedure without any complications. The operative time was 6 hours and 20 minutes and the estimated blood loss was 200cc. The patient tolerated the procedure well and was discharged on postoperative day 5. Conclusion: Purely laparoscopic donor hepatectomy is a highly advanced procedure that aims to decrease enhance the recovery of living donors. Furthermore, this approach is promising to increase the number of liver transplantation performed in North America.

Impact of Middlehepatic Artery Reconstruction after Livingdonor Liver Transplantation Using the Left Lobe

Introduction: The aim of this study was to clarify the impact of middle hepatic artery reconstructionon the outcomesof duct-to-duct biliary anastomosis after living-donor liver transplantation (LDLT) using left lobe.

Hemobilia-a rare complication after laparoscopic cholecystectomy-

BackgroundBiliary bleeding is a condition reported by Sandblom as hemobilia. The most common cause of hemobilia is iatrogenicity. But it has also been reported as a rare complication after laparoscopic cholecystectomy (LC).Case presentationA man in his 60s underwent a LC. He was taking a direct Xa inhibitor for paroxysmal atrial fibrillation (pAf) and had a history of thrombectomy. There was variation in the bifurcation of the hepatic artery and cystic artery. The right hepatic artery branches from the common hepatic artery by itself, and the cystic artery is double. He complained of right upper quadrant pain, nausea, and vomiting on the third postoperative day (3POD). Non-contrast computed tomography (CT) showed that a high absorption area was found to fill the common bile duct. Contrast CT showed no pseudoaneurysm formation. Ultimately, he was diagnosed with postoperative hemobilia. Angiographic examination selective for the cystic artery branching from the middle hepatic artery revealed leakage of the contrast agent and a micro-pseudoaneurysm.ConclusionsWe encountered a case of hemobilia after LC. In this case, it was presumed that in addition to the chronic inflammatory changes of the gallbladder wall, extraordinary bifurcation of the hepatic artery and the cystic arteries and easy bleeding due to resumption of a direct Xa inhibitor synergistically caused a micro-pseudoaneurysm and postoperative hemobilia. It was difficult to identify the cause of hemobilia by contrast CT alone. Angiographic examination was useful for identifying and treating the causative artery and needs to perform aggressively.

Single-Institution Experience with Selective Internal Radiation Therapy (SIRT) for the Treatment of Primary and Secondary Hepatic Tumors.

Purpose: We aim to provide results of the real-world experience of a single center in Lebanon on the use of radioembolization to treat liver-only or liver-dominant tumors. Methods: This retrospective review included patients who were evaluated for radioembolization between January 2015 and June 2017 and who had a lung shunt fraction of 20% or less. Tumor responses were determined using the response evaluation criteria in solid tumors (RECIST).Results: Of the 23 Arab patients with a median age of 64 years (range, 36-87 years), eight had hepatocellular carcinoma, four had cholangiocarcinoma, and 11 had liver-only or liver-dominant metastases from other primary cancers. Most (n=17) had multifocal lesions, and 13 had a history of branched (n=8) or main (n=5) portal vein thrombosis. When appropriate, the gastroduodenal artery and middle hepatic artery were embolized for consolidation of radiotherapy; 18 patients required arterial coil occlusion, two had their cystic artery occluded, and one developed cholecystitis, which was successfully treated with antibiotics and supportive care. Another patient developed a post-radioembolization complication-a peptic ulcer unrelated to arterial reflux of microspheres because both the gastroduodenal and right gastric arteries were occluded. The median time to progression was seven months (range, 3-36 months), and median overall survival from radioembolization was 12 months (range, 3-40 months). Tumor responses included five complete responses, 13 partial responses, one stable disease, and four cases of progressive disease. Conclusion: Performing radioembolization in a non-referral, private center in Lebanon resulted in good patient outcomes with few complications.

Impact of middle hepatic artery reconstruction after living donor liver transplantation using the left lobe.

The aim of this study was to clarify the impact of middle hepatic artery reconstruction on the outcomes of duct-to-duct biliary anastomosis after living donor liver transplantation (LDLT) using the left lobe. Among 258 patients who underwent LDLT using the left lobe, 216 patients who underwent hepatic artery reconstruction and one hepatic duct reconstruction with duct-to-duct interrupted anastomosis were divided into three groups: Group A (n=123), one arterial stump with left hepatic artery reconstruction; Group B (n=32), two arterial stumps with only left hepatic artery reconstruction; and Group C (n=61), two arterial stumps with reconstruction of the left and middle hepatic arteries. The outcomes after LDLT were compared among the three groups. No hepatic artery complications occurred. Group B had a significantly greater incidence of anastomotic biliary stricture than Group C. A multivariate analysis with Cox regression revealed that being in Group B was the only significant independent risk factor for postoperative anastomotic biliary stricture after LDLT. Middle and left hepatic artery reconstruction is safe in LDLT and may prevent biliary stricture caused by dual hepatic artery reconstruction when the graft has left and middle hepatic artery stumps.

Efficacy and safety of guidewireless catheterization with a steerable microcatheter in patients scheduled for yttrium-90 radioembolization: a prospective multicenter trial.

IntroductionA steerable, guidewireless microcatheter is of interest to interventional radiologists because it can improve effectiveness and reduce procedure timing and cost.AimTo assess the feasibility and safety of yttrium 90 radioembolization with a new steerable microcatheter without the need to use a guidewire.Material and methodsA steerable microcatheter (Direxion; Boston Scientific, Natick, MA, USA) was prospectively used for yttrium-90 microsphere delivery in 50 patients (57 applications). The following factors were documented: vessel anatomy; shape and position of the guiding catheter; anticipated catheter position; technical success of catheterization; degree of difficulty in maneuvering; time to reach the target position; and complications.ResultsThe microcatheter target position was in the right hepatic artery (n = 30, 53%), the middle hepatic artery (n = 4, 7%), the left hepatic artery (n = 19, 33%), or in a segmental artery (n = 4, 7%). Vessel catheterization was successful in 53 of 57 hepatic arteries (93%). The mean time to reach the target position was 53.3 ±53.0 s. The mean degree of difficulty in maneuvering the catheter to the target position was 2.3 ±1.3 (easy) on a 6-point scale. The only complication observed was mild vasospasm in 1 patient.ConclusionsThe Direxion steerable microcatheter is characterized by unique steerability, allowing yttrium 90 delivery to be performed safely without use of a guidewire.